BEUDAMED
    FDA Adverse Event Injury Summary report: N

    ADAPTA DR

    MDR report key: 1925171 · Received December 14, 2010

    Report

    Report Number
    6000144-2010-06228
    Event Type
    Injury
    Date Received
    December 14, 2010
    Date of Event
    September 29, 2010
    Manufacturer
    MEDTRONIC MED REL, INC.
    Product Code
    NVZ
    PMA / PMN Number
    P980035/S043
    Removal / Correction Number
    ASKU
    Adverse Event
    Yes
    Product Problem
    Yes
    Report Source
    Manufacturer report
    Reporter Location
    TX, US
    Reporter Occupation
    PATIENT

    Narratives

    Additional Manufacturer Narrative · 1

    THE INFORMATION SUBMITTED REFLECTS ALL RELEVANT DATA RECEIVED. IF ADDITIONAL RELEVANT INFORMATION IS RECEIVED, A SUPPLEMENTAL REPORT WILL BE SUBMITTED.

    Description of Event or Problem · 1

    IT WAS REPORTED BY THE PATIENT THAT THEY PASSED OUT WHEN THE SECURITY WAND WAS USED ON THEM WHILE AT THE COURTHOUSE. THE PATIENT ALSO REPORTED THAT WHEN THE MICROWAVE IS ON AND THEY ARE IN FRONT OF IT, THEY CANNOT MOVE UNTIL IT IS OFF. THE DEVICE REMAINS IN USE. NO FURTHER PATIENT COMPLICATIONS HAVE BEEN REPORTED AS A RESULT OF THIS EVENT.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 ADAPTA DR IMPLANTABLE PULSE GENERATOR NVZ MEDTRONIC MED REL, INC. ADDR01 ASKU

    Patients

    Seq Age Sex Outcome Treatment
    1 35 YR Other 5092 IMPLANTABLE PACING LEAD| 5076 IMPLANTABLE PACING LEAD